Claudia De Simone

Clinical predictors of the efficacy of a pulmonary rehabilitation programme in patients with COPD

OBJECTIVES To identify predictors of success for an 8week pulmonary rehabilitation programme (PRP) in patients with chronic obstructive pulmonary disease (COPD). METHODS Sixty patients were stratified in subgroups according to baseline findings: airway obstruction (FEV(1) >/= or <50% pred), pulmonary hyperinflation (TLC > or <or=120% pred), BMI value (BMI > or <or=25), cardiovascular (CV) comorbidity, and resting PaO(2) (PaO(2) >/= or <60mmHg). Outcome measurements of PRP were: >54m increase in 6min walking test (6MWT), or >4points reduction in total score of S. George Respiratory Questionnaire (SGRQ). Logistic regression analysis was used. RESULTS After PRP there was a significant improvement in exercise tolerance and quality of life, which correlated with baseline FEV(1)/VC, PaO(2), SpO(2), 6MWT and SGRQ. SGRQ significantly decreased and 6MWT significantly increased after PRP in all subgroups, except for patients with CV comorbidities. Both univariate and multivariate logistic regression analyses showed that BMI>25 and resting PaO(2)<60mmHg were independent predictors of PRP efficacy in terms of improvement of 6MWT, but not of SGRQ scores. CONCLUSIONS Clinical and functional baseline findings do not predict the response to PRP in COPD. The greater efficacy in patients with BMI>25 or with PaO(2)<60mmHg may be due to a greater deconditioning in overweight patients, and to a larger room for improvement in hypoxemic patients.

Acute administration of bronchodilators on exercise tolerance in treated COPD patients.

Exercise intolerance is a major feature in patients with Chronic Obstructive Pulmonary Disease (COPD). Bronchodilators increase endurance time (ET) and reduce dynamic hyperinflation (DH). We evaluated whether a single-dose of salbutamol/ipratropium + flunisolide (BD+ICS), added on top of the regular treatment, may improve ET in COPD patients. In a single-blind randomized crossover pilot trial, nebulised BD+ICS or placebo (PL) was administered 30 min before a constant load cardiopulmonary test, in 22 moderate-to-severe COPD patients (FEV₁: 53.9% pred). ET was the primary outcome measured. BD+ICS did not improve ET or VO₂ peak with respect to PL. BD+ICS increased pre-test FEV₁ and pre-test Inspiratory Capacity but did not modify DH. In a retrospective analysis, patients were divided in Improvers (N=11) and Non-Improvers (N=11) according to the difference in ET between BD+ICS and PL (> 25 s). Improvers had a worst BODE index, a higher static hyperinflation and poorer Vd/Vt ratio at peak of exercise with respect to Non-Improvers. Improvers only had a significant increase from BD+ICS on pre-test FEV₁ and IC. In conclusion, although a single-dose BD+ICS did not improve ET in COPD patients under regular treatment, a subgroup of more severe patients may have some benefit from that.

Sputum inflammatory cells in COPD patients classified according to GOLD 2011 guidelines.

Recently the definition of chronic obstructive pulmonary disease (COPD) severity, stated in 2001 by Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines and based on forced expiratory volume in 1 s (FEV1) evaluation, has been considered inadequate to recognise all the multifaceted aspects of the disease. To overcome this limitation, 2011 GOLD recommendations suggested a new approach, which stratified COPD patients in four groups of severity (A, B, C, D) according to the level of symptoms (as assessed by either the modified Medical Research Council (mMRC) score or the COPD Assessment Test), the degree of airflow limitation (expressed as percentage of predicted forced expiratory volume in 1 s (FEV1) value) and the number of exacerbations in the previous year [1]. It is still matter of debate if this new classification helps to better understand the disease and improve COPD treatment and prognosis. Studies on the existing database have been published comparing the old with the new GOLD classifications, showing that GOLD 2011 classification adds new details on the phenotyping and on the prognosis of COPD [2–5]. Despite the many post hoc analyses performed on the large databases of the most important recent observational studies (ECLIPSE, CCLS, COPDgene), the demonstration that these different groups of GOLD 2011 classification are different for physiological and biological features is controversial. The A, B, C and D groups of the new GOLD classification are at least partly related to different COPD phenotypes http://ow.ly/Xgr8q